Skip to content

Advertisement

  • Research article
  • Open Access
  • Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Prescription patterns of traditional Chinese medicine amongst Taiwanese children: a population-based cohort study

  • 1, 2, 3Email author,
  • 4, 5, 6,
  • 7, 8,
  • 1, 2, 3,
  • 1, 2, 3,
  • 9 and
  • 10
BMC Complementary and Alternative Medicine201818:191

https://doi.org/10.1186/s12906-018-2261-2

Received: 13 August 2017

Accepted: 18 June 2018

Published: 22 June 2018

Abstract

Background

Traditional Chinese medicine (TCM) has been used by Chinese patients and in many other countries worldwide. However, epidemiological reports and prescription patterns on children are few.

Methods

A cohort of 178,617 children aged 18 and under from one million randomly sampled cases of the National Health Insurance Research Database was analyzed for TCM prescription patterns. SAS 9.1 was applied and descriptive medicine utilization patterns were presented.

Results

The cohort included 112,889 children treated by TCM, with adolescents (12- to 18-year-olds) as the largest group. In the children’s TCM outpatient visits, Chinese herbal remedies were the main treatment. The top three categories of diseases treated with Chinese herbal remedies were respiratory system; symptoms, signs, and ill-defined conditions; and digestive system. The top three categories using acupuncture were: injury and poisoning, diseases of the musculoskeletal system and connective tissue, and diseases of the respiratory system. Of the top ten herbal medicines prescribed by TCM physicians, the top nine herbal formulae and the top ten single herbs were associated with diseases of the respiratory system.

Conclusion

This study identified patterns of TCM prescriptions for children and common disease categories treated with TCM. The results provide a useful reference for health policy makers and for those who consider the usage of TCM for children.

Keywords

  • Traditional Chinese medicine
  • Chinese herbal remedies
  • Herbal formulae
  • Single herb

Background

Traditional Chinese medicine (TCM) has generally been used not only in adults but also in pediatric patients by the Chinese population, as well as in Asia and many other countries around the world [14]. TCM may include acupuncture, traumatology, manipulative therapies, and moxibustion. Chinese herbal medicines are one of the most common used modes of TCM treatment [5, 6]. In Taiwan, TCM is an important part of health care and is reimbursed under the current National Health Insurance (NHI) system.

TCM application for pediatric disease is popular and widely used because most parents or caregivers believe that TCM, such as herbs, has a therapeutic effect without any harmful consequences [7]. Eighty percent of parents admitted to concurrent usage of TCM and conventional medicine for their children. In Singapore, herbal medicine was the most commonly used form of TCM, at 84.3% [8]. According to previous studies of two randomly sampled cohorts from the National Health Insurance Research Database in Taiwan, 22 and 22.5% of children used TCM in 2005 and 2010 respectively. Among them, herbal remedies were the most commonly used therapeutic approach, followed by manipulative therapy and acupuncture. In addition, there was an increasing trend of using herbal remedies (from 65.6 to 74.4%) and acupuncture (from 7.5 to 11.4%) from 2005 to 2010 [6]. In another national cohort of 112,159 children < 12 years, 18.3% had used TCM; school-age children (aged 6–12 years), preschool age children (3–5 years), and toddlers (1–2 years) were more likely to use TCM than infants [9]. However, children are vulnerable to drugs [10], so the dosage varies with age and sensitivity. Little is known about patterns of use of TCM in conditions related to childhood disease and adolescent disease; further study might increase the potential for traditional medicine to be used in Western countries. Accordingly, the computerized reimbursement database of the NHI, the National Health Insurance Research Database (NHIRD), stores longitudinal data on TCM; it also provides an optimal platform for the understanding of use patterns of TCM for children. Thus, the aim of our study is to analyze a random sample of this database and to determine TCM utilization patterns for children aged 18 years and under in Taiwan by analyzing NHI claims data from 2005 to 2013.

Methods

Data source

In the health care system in Taiwan, people are free to choose between Western medicine and TCM, and are allowed to visit either primary care clinics or hospitals without referral. Furthermore, NHI covers almost the entire Taiwanese population, accounting for 99.6% of the total population (23,737,000 beneficiaries at the end of 2015) [11, 12]. All TCMs are provided and prescribed by physicians, and all are covered by NHI. In addition, only licensed TCM physicians qualify for reimbursement. The insurance coverage for TCM in Taiwan includes Chinese herbal medicine (CHM), acupuncture, and traumatology manipulative therapy. TCM medical records files include medical care facilities and specialties; drugs and other management for treatment; and patients’ gender, date of birth, date of health care encounter, and unique identification number, which is used to protect the confidentiality of the patient’s individually identifiable information, as is the case for Western medication [13]. According to the construct of the database, the dataset reflected primary treatment only, meaning that if children were treated with both acupuncture and herbs, only the herbal treatment was recorded. Furthermore, three major diagnoses were coded in the International Classification of Disease, 9th Revision, and Clinical Modification (ICD-9-CM) format. These databases have previously been used for epidemiologic research and information on prescription use, diagnoses, and hospitalizations. In this study, a cohort of one million patients who were beneficiaries of the NHI program from January 1, 2005, to December 31, 2013, was randomly sampled. From the sampled group, we extracted children aged 18 years and younger for whom TCM was utilized. Patients with missing data on sex or birthdate were excluded.

Following strict confidentiality guidelines in accordance with personal electronic data protection regulations, the National Health Research Institute of Taiwan maintains an anonymous database of NHI reimbursement data that is suitable for research. In addition, this study was approved by the Ethics Review Board of Chang Gung Memorial Hospital, Chiayi Branch, Taiwan.

Study subjects

For this study, we screened 178,617 eligible children aged from newborn to 18 years from the random cohort sample. The age was calculated by subtracting the birth date of the subject from December 31, 2013. We assembled a database of all outpatient department TCM records for 2005–2013 and included for final analysis the 112,889 subjects who had visited a TCM outpatient department at least once.

Products of herbal formula (HF) and single herbs (SH)

TCM has developed over the past millennia and is a well-established component of the national health system in Taiwan. Its practice includes Chinese herbal remedies (CHR), acupuncture, and traumatology manipulative therapies; these are reimbursed by the NHI of Taiwan [13]. We downloaded the list of reimbursed Chinese herbal products from the website of the Bureau of NHI. Corresponding drug information on a specific mixture or name was then obtained from the Committee on Chinese Medicine and Pharmacy (CCMP) website, including the proportions of each constituent, date and period of drug approval, drug names, and manufacturers’ codes. Products of SH or HF are assigned with different drug registration numbers if produced by different manufacturers even though the constituents are the same. There are 2485 drug registration numbers for SH and 6639 drug registration numbers for HF, which involve 391 kinds of herbs based on 309 HF according to the unified formula announced by CCMP; all unified formulae were chosen from seven Chinese medicine books.

Statistical analysis

We used SAS version 9.1 software (SAS Institute Inc., Cary, NC) for data analysis and descriptive statistics of drug utilization patterns. We linked drug registration numbers from the CCMP website to outpatient visit records of the study cohort. Then we analyzed the frequencies and percentages of the most frequently used HF and SH prescriptions. We calculated average daily doses and durations for each prescription. The TCM records include data indicating which SH or HF was prescribed, the prescription duration in days, and the dosage in grams. We used the following formula to calculate the average daily dose for SH and HF in the present study: (total dosage for SH or HF)/(total amount of prescription day for SH or HF) = average daily dose for SH or HF.

By using the ICD-9-CM of the first major diagnosis, records of visiting outpatient departments can be divided into different disease categories. We also analyzed the three most commonly used HF and SH for the five most common disease categories for the subjects.

Results

A total of 112,889 out of 178,617 (63.2%) subjects that had TCM treatments between 2005 and 2013 were analyzed. Table 1 shows there were 11,448 children (10.1%) in the 0–5-year-old age group, 43,940 children (38.9%) in the 6–11-year-old age group, and 57,501 children (50.9%) in the 12–18-year-old age group who were treated as TCM outpatients. Analyses identified a significant difference in gender and age groups (p < 0.0001).
Table 1

TCM used among children in different age groups (n = 112,889)

Age (years)

0–5(preschool and under)

6–11(school)

12–18(adolescent)

Total

p value

 

n

%

n

%

n

%

n

%

<  0.0001

Boys

6223

54.4a (10.8)b

23,040

52.4 (40.0)

28,384

49.4 (49.2)

57,647

51.1 (100.0)

 

Girls

5225

45.6 (9.5)

20,900

47.6 (37.8)

29,117

50.6 (52.7)

55,242

48.9 (100.0)

 

Total

11,448

100.0 (10.1)

43,940

100.0 (38.9)

57,501

100.0 (50.9)

112,889

100.0 (100.0)

 

Results are n and % using x2 test

aColumn percentage

bRow percentage

Table 2 shows frequency distributions of TCM visits classified by major disease categories (according to ICD-9-CM codes). Of the 1,588,900 TCM outpatient visits among these children, 1,440,316 (90.6%) were treated with prescriptions of CHR, and 148,584 (9.4%) were treated with prescribed acupuncture and manipulative therapies. The top five categories of disease treated with TCM were: diseases of the respiratory system (42.9%); symptoms, signs, and ill-defined conditions (19.0%); diseases of the digestive system (10.6%); injury and poisoning (9.2%); and diseases of the skin and subcutaneous tissue (6.7%). These diseases or conditions accounted for more than 88.4% of all TCM visits. The top five major disease categories for which CHR was prescribed were diseases of the respiratory system (47.2%); symptoms, signs, and ill-defined conditions (21.0%); diseases of the digestive system (11.6%); diseases of the skin and subcutaneous tissue (7.4%); and disease of the genitourinary system (6.5%). These conditions accounted for more than 93.7% of CHR among all TCM visits. Moreover, injury and poisoning and diseases of the musculoskeletal system and connective tissue accounted for more than 97.4% of TCM visits using acupuncture and traumatology.
Table 2

Frequency distribution of TCM visits by major disease categories among children 18 years and younger

Major disease category

ICD-9-CM

Chinese herbal remedies

Acupuncture traumatology

Total of TCM

n (%)

Rank

n (%)

Rank

n (%)

Rank

Diseases of the Respiratory System

460–519

679,509(47.2)

1

1354(0.9)

3

680,863(42.9)

1

Symptoms, Signs, and Ill-Defined Conditions

780–799

301,712(21.0)

2

392(0.3)

7

302,104 (19.0)

2

Diseases of the Digestive System

520–579

167,701 (11.6)

3

245(0.2)

8

167,946 (10.6)

3

Diseases of the Skin and Subcutaneous Tissue

680–709

106,547 (7.4)

4

176(0.1)

10

106,723 (6.7)

5

Diseases of the Genitourinary System

580–629

94,168 (6.5)

5

2294(0.2)

4

96,462 (6.1)

6

Injury and Poisoning

800–999

25,573 (1.8)

6

121,101 (82.7)

1

146,674 (9.2)

4

Diseases of the Musculoskeletal System and Connective Tissue

710–739

24,109 (1.7)

7

21,523 (14.7)

2

45,632 (2.9)

7

Diseases of the Nervous System and Sense Organs

320–389

15,066 (1.1)

8

611(0.4)

5

15,677 (0.9)

8

Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders

240–279

7230 (0.5)

10

72(0.0)

11

7302(0.5)

10

Mental Disorders

290–319

6373 (0.4)

11

227(0.2)

9

6600(0.4)

11

Othersa

 

12,328(0.9)

9

589(0.4)

6

12,917(0.8)

9

Total

 

1440,316(100)

 

148,584(100)

 

1,588,900 (100)

 

aOthers include ICD-9-CM code ranges 280–289, 630–677, 740–759, 760–779, V01-V82, E800-E999

Since CHR were the most common prescription, Table 3 displays the 10 most commonly prescribed HF and SH for children. It also includes the frequency of prescriptions, average daily doses (in grams) by age group, and average prescription duration (in days). In HF, the average daily dose was 2.5–3.1 g for children 0–5 years of age, 3.3–3.9 g for children 6–11 years of age, and 3.8–4.7 g for children 12–18 years of age; the average prescription durations were 5.5–7.2 days. The most commonly prescribed HF for children was Shin-Yi-Ching-Fey-Tang (SYCFT) (14.8%). The next four top HF were Xiao-Qing-Long-Tang (XQLT) (10.9%), Cang-Er-San (9.9%), Xin-Yi-San (XYS) (9.8%), and Ma-Xin-Gan-Shi-Tang (MXGST) (9.7%).
Table 3

Top ten herbal medicine prescribed by traditional Chinese physicians for children

Rank

Herbal formulae

Frequency (%)

Average daily doses (g), by age group

Average duration (days)

Single herb

Frequency (%)

Average daily doses (g), by age group

Average duration (days)

0–5

6–11

12–18

   

0–5

6–11

12–18

 

1

Shin-Yi-Ching-Fey-Tang

213,325 (14.8)

2.9

3.6

4.1

6.5

Gan-Cao

(Radix Glycyrrhizae)

165,315 (11.5)

0.8

0.8

1.0

6.3

2

Xiao-Qing-Long-Tang

157,380 (10.9)

3.1

3.7

4.4

6.9

Jie-Geng

(Radix Platycodi)

134,474 (9.3)

1.2

1.3

1.3

5.9

3

Cang-Er-San

142,826 (9.9)

2.8

3.3

3.8

6.4

Chuan-Bei-Mu

(Bulbus Fritillariae Cirrhosae)

122,641 (8.5)

1.0

1.1

1.2

6.1

4

Xin-Yi-San

141,049 (9.8)

3.0

3.8

4.4

6.8

Yu-Xing-Cao

(Herba Houttuyniae)

117,641 (8.2)

1.2

1.3

1.4

6.0

5

Ma-Xing-Gan-Shi-Tang

139,927 (9.7)

3.0

3.6

4.1

5.7

Xing-Ren

(Semen Armeniacae)

102,099 (7.1)

1.2

1.2

1.3

6.0

6

Yin-Qiao-San

110,639 (7.7)

2.9

3.7

4.3

5.5

Huang-Qin

(Radix Scutellariae)

100,846 (7.0)

1.3

1.4

1.5

6.2

7

Xin-Su-San

96,869 (6.7)

3.1

3.7

4.4

5.7

Chan-Tui

(Cryptotympana atrata Fabr)

100,428 (7.0)

1.0

1.1

1.2

6.7

8

Ge-Gen-Tang

95,719 (6.6)

3.0

3.9

4.7

6.5

Bai-Zhi

(Radix Angelicae Dahuricae)

94,423 (6.6)

1.2

1.3

1.4

6.6

9

Zhi-Sou-San

74,483 (5.2)

2.8

3.4

4.0

5.7

Cang-Er-Zi

(Fructus Xanthii)

84,896 (5.9)

1.1

1.2

1.3

6.5

10

Jia-Wei-Xiao-Yao-San

70,066 (4.9)

2.5

3.8

4.4

7.2

Xin-Yi

(Flos Magnoliae)

68,746 (4.8)

1.2

1.3

1.4

6.3

In SH, the average daily dose was 0.8–1.3 g for children 0–5 years of age, 0.8–1.4 g for children 6–11 years of age, and 1.0–1.5 g for children 12–18 years of age; the average prescription durations were 5.9–6.7 days. Gan-Cao (Radix Glycyrrhizae) (11.5%) was the most commonly prescribed SH for children. The next four most frequently prescribed SH were Jie-Geng (Radix Platycodi) (9.3%), Chuan-Bei-Mu (Bulbus Fritillariae Cirrhosae) (8.5%), Yu-Xing-Cao (Herba Houttuyniae) (8.2%), and Xing-Ren (Semen Armeniacae) (7.1%).

Regarding TCM used with CHR, Table 4 presents the most frequently used HF and SH for the five most common disease categories. SYCFT (25.7%), XQLT (18.8%), and XYS (18.1%) were the most common HF prescribed, and Gan-Cao (14.3%), Yu-Xing-Cao (13.3%), and Jie-Geng (13.1%) were the most common SH prescribed for respiratory system diseases. MXGST (14.1%), SYCFT (12.3%), and Xin-Su-San (11.5%) were the most frequently prescribed HF, and Jie-Geng (14%), Chuan-Bei-Mu (13.2%), and Gan-Cao (11.1%) were the most commonly prescribed SH for symptoms, signs, and ill-defined conditions. For diseases of the digestive system, Xiang-Sha-Liu-Jun-Zi-Tang (16.1%), Shen-Ling-Bai-Zhu-San (SLBZS) (16%), and Bao-He-Wan (15.2%) were the three most frequently used HF, and Shen-Qu (15.3%), Mai-Ya (14%), and Shan-Zha (11.2%) were the most commonly used SH. Xiao-Feng-San (XFS) (23.9%), Qing-Shang-Fang-Feng-Tang (QSFFT) (23.3%), and Zhen-Ren-Huo-Ming-Yin (17%) were the most frequently used HF, and Lian-Qiao (21.6%), Jin-Yin-Hua (16.7%), and Pu-Gong-Ying (15.4%) were the most frequently used SH for diseases of the skin and subcutaneous tissue. For genitourinary system diseases, Jia-Wei-Xiao-Yao-San (32.2%), Dang-Gui-Shao-Yao-San (18%), and Wen-Jing-Tang (16.7%) were the three most commonly used HF, while Xiang-Fu (21.7%), Yi-Mu-Cao (21.5%), and Yan-Hu-Suo (13.6%) were the most frequently prescribed SH.
Table 4

Three most common herbal medicine for five most common disease categories in children

Diseases categories

Herbal formulae

Single herb

  

Frequency (%)

 

Frequency (%)

Diseases of the Respiratory System

Shin-Yi-Ching-Fey-Tang

166,463 (25.7)

Gan-Cao

(Radix Glycyrrhizae)

92,530 (14.3)

Xiao-Qing-Long-Tang

121,716 (18.8)

Yu-Xing-Cao

(Herba Houttuyniae)

86,083 (13.3)

Xin-Yi-San

117,546 (18.1)

Jie-Geng

(Radix Platycodi)

85,060 (13.1)

Symptoms, Signs, and Ill-Defined Conditions

Ma-Xing-Gan-Shi-Tang

39,987 (14.1)

Jie-Geng

(Radix Platycodi)

39,658 (14.0)

Shin-Yi-Ching-Fey-Tang

34,987 (12.3)

Chuan-Bei-Mu

(Bulbus Fritillariae Cirrhosae)

37,366 (13.2)

Xin-Su-San

32,792 (11.5)

Gan-Cao

(Radix Glycyrrhizae)

31,433 (11.1)

Diseases of the Digestive System

Xiang-Sha-Liu-Jun-Zi-Tang

24,784 (16.1)

Shen-Qu

(Massa Medicata Fermentata)

23,520 (15.3)

Shen-Ling-Bai-Zhu-San

24,642 (16.0)

Mai-Ya

(Fructus Hordei Germinatus)

21,490 (14.0)

Bao-He-Wan

23,364 (15.2)

Shan-Zha

(Fructus Crataegi)

17,203 (11.2)

Diseases of the Skin and Subcutaneous Tissue

Xiao-Feng-San

22,286 (23.9)

Lian-Qiao

(Fructus Forsythiae)

20,107 (21.6)

Qing-Shang-Fang-Feng-Tang

21,723 (23.3)

Jin-Yin-Hua

(Flos Lonicerae)

15,588 (16.7)

Zhen-Ren-Huo-Ming-Yin

15,831 (17.0)

Pu-Gong-Ying

(Taraxacum officinale)

14,355 (15.4)

Diseases of the Genitourinary System

Jia-Wei-Xiao-Yao-San

25,164 (32.2)

Xiang-Fu

(Rhizoma Cyperi)

16,977 (21.7)

Dang-Gui-Shao-Yao-San

14,102 (18.0)

Yi-Mu-Cao

(Herba Leonuri)

16,833 (21.5)

Wen-Jing-Tang

13,049 (16.7)

Yan-Hu-Suo

(Rhizoma Corydalis)

10,656 (13.6)

Discussion

To date, this study is the most comprehensive investigation of TCM usage among children aged 18 years and younger. The advantages of the study are in the application of a random national-level sample to analyze and document comprehensive data gathered with unrestricted access, and is particularly valid for investigating TCM. However, children may be taken for treatment to other places, such as where folk medicine is practiced, and these are not included in the database. The number of TCM patients may be underestimated. That is the limitation of this study. The integration of TCM into the health care system in Taiwan has resulted in the NHIRD providing a large database of TCM usage with de-identified patient information. Previous studies have mainly consisted of questionnaire surveys or telephone interviews from hospitals or private clinics, mostly obtaining parents’ or caregivers’ information [7, 8, 14, 15]. Therefore, results were limited because of small sample sizes. Additionally, young children may be unable to express ideas clearly, and most of them are protected by parents or family caregivers without the chance to present their opinions freely. Therefore, these previous studies might only offer a limited picture of children’s TCM usage. Because TCM is reimbursed by Taiwan’s NHI, the results of this study could reveal a broad, less biased description and overview of children’s TCM usage.

We found adolescents occupied the greatest portion (50.9%) of all TCM age groups among the 112,889 child TCM patients selected. The findings of the most common TCM use group among children is consistent with previous studies [1, 6], which showed that as a child grows older, preference for pediatric TCM use increases. However, the prevalence of TCM use was represented differently; Huang et al. [6] showed 38.4% adolescent TCM use in 2005, and 42.7% in 2010. Our study showed 50.9% adolescent TCM use in 2005–2013. Several scholars identified the role of puberty in TCM treatment of adolescents, citing the physiological and behavioral changes associated with the attainment of reproductive competence as well as nonreproductive traits, such as social, emotional, and cognitive developmental factors associated with the transition from childhood to adulthood [16, 17]. However, another investigation [9] indicated that children’s age and parental TCM use were more strongly associated with TCM use, with parental TCM use being the most important factor influencing pediatric TCM use.

In our study, respiratory system diseases were the most common reason for children to visit TCM clinics, followed by symptoms, signs, and ill-defined conditions; digestive system diseases; injury and poisoning; and diseases of the skin and subcutaneous tissue. A previous study has revealed similar findings. Huang et al. [6] analyzed the use of TCM in children based on two random cohorts in 2005 and 2010 of NHIRD. The frequency distributions of diseases treated with TCM concurred with our study, but their study showed a different ordering of the reasons for children’s TCM visits. It indicated that respiratory system diseases remained the most common reason for children to visit TCM clinics in Taiwan in 2005 and 2010, followed by symptoms, signs, and ill-defined conditions; injury and poisoning; digestive system diseases; and diseases of the skin and subcutaneous tissue. Our findings differed from the previous study [9], indicating that musculoskeletal problems were the most common underlying medical conditions among children TCM users, followed by gastrointestinal problems and respiratory problems. Our results differed slightly when compared to the entire population of TCM users in Taiwan. As Chen’s study [14] showed, the top five most common reasons for TCM visits were diseases of the respiratory system; musculoskeletal system and connective tissue; symptoms, signs, and ill-defined conditions; injury and poisoning; and diseases of the digestive system. These findings could be explained by the frequency distributions of diseases for which TCM is commonly used. TCM contributes to the treatment of these diseases and plays a significant role in improving children’s health.

Additionally, a high-quality, pediatric asthma outpatient TCM clinic project was administered by Taiwan’s bureau of National Health Insurance and the National Union of Chinese Medical Doctors’ Association, ROC. This project benefited children with asthma [18, 19]. The project was piloted in 2006 for asthmatic children under 15 years old in and was fully implemented in 2013 for children 12 years old and under [20]. As a result of this program’s positive impacts for asthmatic children, the prevalence of TCM used for children may increase. Further studies are suggested to explore these potential effects.

Chinese herbal remedies (90.6%) (Table 2) comprised most TCM visits. Among them, respiratory system diseases were the leading ailment to be treated in our study. Furthermore, we found that most top ten herbal medicines including HF and SH prescribed by physicians (Table 3) were associated with treating respiratory disease. Thus, children and adolescents with respiratory disease were more likely to use TCM, especially CHR. Injury and poisoning were the most frequent conditions associated with acupuncture traumatology use, although acupuncture therapy occurred in few TCM visits (9.4%) in our study. In line with Lu, Chang, Sung, and Chen’s study [21], acupuncture is one of the most common treatment modalities used in injury management, and is likely to be common in patients with dislocations, sprains, and strains because of the effectiveness of TCM modalities on pain management and function improvement. Previous studies [22, 23] have reported that acupuncture helps in alleviating pain, chronic pain, and other conditions. Although the potential for acupuncture not to be accepted among pediatric populations exists because children are often afraid of needles, some studies have depicted pediatric acupuncture as both acceptable and feasible [24, 25]. However, different characteristics of disease may indicate different patterns of acupuncture use among children. Further studies are recommended to determine these patterns.

We further determined that SYCFT, XQLT, Xin-Yi-San in HF, and Gan-Cao, Yu-Xing-Cao, and Jie-Geng in SH, were the top three herbal medicines prescribed for diseases of the respiratory system (Table 4). Gan-Cao is commonly prescribed by TCM physicians for children because of the adjustment of taste [26, 27]. Symptoms, signs, and ill-defined conditions were the second most frequent diagnoses for TCM visits with prescriptions for CHR in our study. Furthermore, we found that HF and SH often used for diseases of the respiratory system were commonly used for symptoms, signs, and ill-defined conditions. Thus, we inferred that most patients who were treated for symptoms, signs, and ill-defined conditions suffered from diseases related to the respiratory system.

Traditionally, TCM physicians always chose therapeutic principles and methods based on syndrome differentiation theory and did not make specific diagnoses based on holistic considerations in patients with many different symptoms. Syndrome differentiation is a unique method for the diagnosis of disease in TCM, using the concepts of balance and harmony to analyze the patterns within the human body and make a diagnosis [28]. However, because younger children are unable to express themselves clearly, the diagnostic process is combined with clinical treatment into a holistic approach to determine patterns of dysfunction and treatment [29]. Moreover, there is no standard methodology in the disease coding system for TCM [13]. This may be why TCM physicians use the ICD-9-CM code for symptoms, signs, and ill-defined conditions instead of using specific diagnostic codes. It is important to develop more reliable coding systems for TCM diagnostic classifications.

Jia-Wei-Xiao-Yao-San (JWXYS) was the only exception in the top ten list in that it was not related to respiratory disease. It occupied tenth position (Table 3). However, it was the top commonly prescribed HF, followed by Dang-Gui-Shao-Yao-San (DGSYS) and Wen-Jing-Tang (WJT) for treating diseases of the genitourinary system (Table 4) in our study. Our finding is similar to previous studies [30, 31] that found DGSYS was the most commonly used HF, followed by JWXYS and WJT, to treat primary dysmenorrhea for women 13–25 years old, and 20–50 years old respectively. Dysmenorrhea is a common gynecological complaint of adolescent girls who often suffer from some level of discomfort due to menstruation [31, 32]. Our results correspond to a previous study [33], which concluded JWXYS was most often used for primary dysmenorrhea, followed by DGSYS and WJT, among HF; additionally, Xiang-Fu (Cyperus rotundus L.), Yi-Mu-Cao (Leonurus heterophyllus Sweet), and Yan-Hu-Suo (Corydalis yanhusuo W. T. Wang) were the most commonly used SH to treat diseases of the genitourinary system in our study. Furthermore, SH is often used as an adjuvant to HF; however, both SH of Xiang-Fu and Yi-Mu-Cao were prescribed more frequently than the HF of DGSYS in our study. According to TCM theory, the organs work together by regulating and preserving Qi (energy) and blood through the so-called channels and collaterals. Qi stagnation usually suggests that energy and information cannot move smoothly to or from its appropriate location [29]. Xiang-Fu is used to treat qi stagnation, and Yi-Mu-Cao is used to treat blood stasis [34]. It has been used to treat dysmenorrhea and irregular menstruation [30, 35].

XSLJZT is the most commonly prescribed HF for diseases of the digestive system. It is a common Chinese herbal prescription and used for the treatment of gastrointestinal diseases in Asian countries [36]. SLBZS enhances digestive function and removes moisture to clear digestive discomforts like diarrhea and distension [37, 38]. Shen-Qu was the most commonly prescribed SH to treat diseases of the digestive system in our study. In traditional Chinese medicine, Shen-Qu is used to treat conditions such as diarrhea, abdominal distension, and lack of appetite. Shen-Qu can also inhibit the activity of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) and maintain the balance of cholesterol in the body [39].

XFS was the most commonly prescribed HF, followed by QSFFT and Zhen-Ren-Huo-Ming-Yin, for diseases of the skin and subcutaneous tissue in our study. Previous studies [40, 41] found XFS was the most commonly prescribed Chinese herbal formula for atopic dermatitis and urticaria since it has an antipruritic effect for severe, refractory, extensive, and non-exudative atopic dermatitis [42]. Chien et al. [41] found that XFS was by far the most commonly prescribed Chinese HF for subjects with urticarial by analyzing the population-based CHM database from Taiwan. Furthermore, this herbal remedy helps address weepy, itchy, red skin lesions such as eczema, urticarial, psoriasis, and diaper rash. A previous study [43] found QSFFT was the most commonly used HF, followed by Zhen-Ren-Huo-Ming-Yin, among 279,823 CHM prescriptions to treat acne. We found Lian-Qiao, Jin-Yin-Hua, and Pu-Gong-Ying, often used as antibiotics in Chinese medicine [44, 45], were the most commonly prescribed SH for the treatment of diseases of the skin and subcutaneous tissue.

Chinese herbal products were invented about 40 years ago and have been utilized ever since [13]. There are no guidelines for children’s Chinese herbal product dosages. Thus, TCM doctors typically adjust the dosage according to their clinical experience, the patient’s age, and/or the patient’s body weight. Our research provides the average daily dose and treatment duration for the top ten herbal medicines commonly prescribed by TCM physicians for children in Taiwan.

Conclusion

We conducted a nationwide, population-based study on the use of TCM in children 18 years of age and younger based on one randomly selected cohort from the 2005–2013 NHIRD healthcare claims data in Taiwan. TCM usage is common, with approximately 63.2% of children having been treated with it. The utilization increased with age, peaking in the 12- to 18-year-old age group. Respiratory system diseases were the most common reason for TCM treatment, and Chinese herbal remedies were the most commonly used TCM modality. Shin-Yi-Ching-Fey-Tang and Gan-Cao (Radix Glycyrrhizae) were the most commonly used formula and single herb. This study provides information about the prescription patterns of TCM and disease categories treated by TCM, which should be useful for health policy makers and for those who consider the usage of TCM for children.

Abbreviations

CCMP: 

Committee on Chinese Medicine and Pharmacy

CHM: 

Chinese herbal medicine

CHR: 

Chinese herbal remedies

HF: 

Herbal formula

ICD-9-CM: 

International classification of disease, 9th revision, clinical modification

JWXYS: 

Jia-Wei-Xiao-Yao-San

MXGST: 

Ma-Xin-Gan-Shi-Tang

NHI: 

National Health Insurance

NHIRD: 

National Health Insurance Research Database

SH: 

Single herb

SLBZS: 

Shen-Ling-Bai-Zhu-San

SYCFT: 

Shin-Yi-Ching-Fey-Tang

TCM: 

Traditional Chinese medicine

XFS: 

Xiao-Feng-San

XQLT: 

Xiao-Qing-Long-Tang

XSLJZT: 

Xiang-Sha-Liu-Jun-Zi-Tang

XYS: 

Xin-Yi-San

Declarations

Acknowledgements

The study data were obtained from the NHIRD provided by the National Health Insurance Administration, Ministry of Health and Welfare of Taiwan, and managed by the National Health Research Institutes of Taiwan. The interpretation and conclusions contained herein do not represent those of the National Health Insurance Administration, Ministry of Health and Welfare, or National Health Research Institutes of Taiwan. Furthermore, the authors would like to thank the Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi Branch for the technical support services.

Funding

This study was supported by a grant from Chang Gung Memorial Hospital, Chiayi Branch (CLRPG6G0041). The funding body had no involvement in the design of the study and collection, analysis and interpretation of data and in writing of this manuscript.

Availability of data and materials

The raw dataset is not available publically due to Taiwan’s privacy regulations. Interested and qualified researchers can obtain the data through formal application to the NHIRD, Taiwan at http://nhird.nhri.org.tw.

Authors’ contributions

HFL, YHY, and KMW conceptualized the study. YHY, PCC, and CHC performed the statistical analysis. PCC, HCK, CHC, and YHW contributed to the interpretation of TCM data. HFL and YHW contributed to the interpretation of identified patterns of TCM use among children. YHY, HCK, and YHW interpreted the pharmacological mechanisms. HFL and KMW drafted the manuscript and YHY finalized the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was approved by Chang Gung Medical Foundation Institutional Review Board, and access to the National Health Insurance Research Database (NHIRD) was permitted by the National Health Research Institutes in Taiwan. Since the identification numbers of all subjects in the NHIRD were encrypted to protect the privacy of the individuals, the informed consents were waived. All the lack of consent forms is in accordance with Chapter II, “Information Collection, Processing and Use by a Government Agency”, of the Personal Information Protection Act of Taiwan.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Nursing, Chang Gung University of Science and Technology, Puzi City, Taiwan
(2)
Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Puzi City, Taiwan
(3)
Chang Gung Memorial Hospital, Chiayi, Puzi City, Taiwan
(4)
Department for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
(5)
Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
(6)
School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
(7)
Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
(8)
Department of Environmental and Occupational Medicine, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
(9)
Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi, Taiwan
(10)
Department of Early Childhood Education, National Chiayi University, Chiayi, Taiwan

References

  1. Shih CC, Liao CC, Su YC, Yeh TF, Lin JG. The association between socioeconomic status and traditional chinese medicine use among children in Taiwan. BMC Health Serv Res. 2012;12:27.View ArticlePubMedPubMed CentralGoogle Scholar
  2. Du Y, Wolf IK, Zhuang W, Bodemann S, Knöss W, Knopf H. Use of herbal medicinal products among children and adolescents in Germany. BMC Complement Altern Med. 2014;14:218.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Yeh YH, Chou YJ, Huang N, Pu C, Chou P. The trends of utilization in traditional Chinese medicine in Taiwan from 2000 to 2010: a population-based study. Medicine. 2016;95(27):e4115.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Mitidieri A, Gurian MB, Silva AP, Tawasha K, Poli-Neto O, Nogueira A, et al. Evaluation of women with myofascial abdominal syndrome based on traditional Chinese medicine. Aust J Pharm. 2015;18(4):26–31.Google Scholar
  5. Chen YC, Lin YH, Hu S, Chen HY. Characteristics of traditional Chinese medicine users and prescription analysis for pediatric atopic dermatitis: a population-based study. BMC Complement Altern Med. 2016;16:173.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Huang TP, Liu PH, Lien AS, Yang SL, Chang HH, Yen HR. A nationwide population-based study of traditional Chinese medicine usage in children in Taiwan. Complement Ther Med. 2014;22(3):500–10.View ArticlePubMedGoogle Scholar
  7. Hon KL, Ma KC, Wong Y, Leung TF, Fok TF. A survey of traditional Chinese medicine use in children with atopic dermatitis attending a paediatric dermatology clinic. J Dermatolog Treat. 2005;16(3):154–7.View ArticlePubMedGoogle Scholar
  8. Loh CH. Use of traditional Chinese medicine in Singapore children: perceptions of parents and paediatricians. Singap Med J. 2009;50(12):1162–8.Google Scholar
  9. Chen HY, Lin YH, Wu JC, Chen YC, Thien PF, Chen TJ, et al. Characteristics of pediatric traditional Chinese medicine users in Taiwan: a nationwide cohort study. Pediatrics. 2012;129(6):e1485–92.View ArticlePubMedGoogle Scholar
  10. Poole RL, Carleton BC. Medication errors: neonates, infants and children are the most vulnerable. J Pediatr Pharmacol Ther. 2008;13(2):65–7.PubMedPubMed CentralGoogle Scholar
  11. Wu TY, Majeed A, Kuo KN. An overview of the healthcare system in Taiwan. London J Prim Care (Abingdon). 2010;3(2):115–9.View ArticleGoogle Scholar
  12. National Health Insurance Administration. Statistical annual reports, the National Health Insurance Statistics, 2015. In Edited by Ministry of Health and Welfare, Taiwan.Google Scholar
  13. Yang YH, Chen PC, Wang JD, Lee CH, Lai JN. Prescription pattern of traditional Chinese medicine for climacteric women in Taiwan. Climacteric. 2009;12(6):541–7.View ArticlePubMedGoogle Scholar
  14. Chen FP, Chen TJ, Kung YY, Chen YC, Chou LF, Chen FJ, et al. Use frequency of traditional Chinese medicine in Taiwan. BMC Health Serv Res. 2007;7:26.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Genc RE, Senol S, Turgay AS, Kantar M. Complementary and alternative medicine used by pediatric patients with cancer in western Turkey. Oncol Nurs Forum. 2009;36(3):E159–64.View ArticlePubMedGoogle Scholar
  16. Walker DM, Bell MR. Adolescence and reward: making sense of neural and behavioral changes amid the chaos. J Neurosci. 2017;37(45):10855–66.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Lin YC, Chang TT, Chen HJ, Wang CH, Sun MF, Yen HR. Characteristics of traditional Chinese medicine usage in children with precocious puberty: a nationwide population-based study. J Ethnopharmacol. 2017;205:231–9.View ArticlePubMedGoogle Scholar
  18. Chung YY, Lin YT, Lin JC. Effectiveness analysis of Chinese medicine pediatric asthma trial project and future development. Taiwan J Chin Med. 2013;11(1):27–37.Google Scholar
  19. Liao PS, Chen CL, Hsieh YH, Hou YC. Research on the health service quality in traditional Chinese medicine-ßased on traditional Chinese medical highquality outpatient clinic pilot project of pediatric asthma in remission stage. J Integr Chin West Med. 2010;12(1):11–20.Google Scholar
  20. National Health Insurance. High-quality care to relieve pediatric asthma in TCM. In Edited by National Health Insurance. National Health Insurance Bimonthly. 2014;109:30–33.Google Scholar
  21. Lu CY, Chang HH, Sung FC, Chen PC. Characteristics of traditional Chinese medicine use in pediatric dislocations, sprains and strains. Int J Environ Res Public Health. 2017;14(2):153.View ArticlePubMed CentralGoogle Scholar
  22. Kemper KJ, Sarah R, Silver-Highfield E, Xiarhos E, Barnes L, Berde C. On pins and needles? Pediatric pain patients’ experience with acupuncture. Pediatrics. 2000;105(4 Pt 2):941–7.PubMedGoogle Scholar
  23. Lin YC, Tassone RF, Jahng S, Rahbar R, Holzman RS, Zurakowski D, et al. Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Paediatr Anaesth. 2009;19(11):1096–101.View ArticlePubMedGoogle Scholar
  24. Zeltzer LK, Tsao JC, Stelling C, Powers M, Levy S, Waterhouse M. A phase I study on the feasibility and acceptability of an acupuncture/hypnosis intervention for chronic pediatric pain. J Pain Symptom Manag. 2002;24(4):437–46.View ArticleGoogle Scholar
  25. Brittner M, Le Pertel N, Gold MA. Acupuncture in Pediatrics. Curr Probl Pediatr Adolesc Health Care. 2016;46(6):179–83.View ArticlePubMedGoogle Scholar
  26. Ho SQ. Zhang Zhongjing views of Gan-Cao. J Chin Clin. 2003;31(7):52–3.Google Scholar
  27. Zhang Q, Ye M. Chemical analysis of the Chinese herbal medicine Gan-Cao (licorice). J Chromatogr A. 2009;1216(11):1954–69.View ArticlePubMedGoogle Scholar
  28. Lu AP, Jia HW, Xiao C, Lu QP. Theory of traditional Chinese medicine and therapeutic method of diseases. World J Gastroenterol. 2004;10(13):1854–6.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Mei MF. A systematic analysis of the theory and practice of syndrome differentiation. Chin J Integr Med. 2011;17(11):803–10.View ArticlePubMedGoogle Scholar
  30. Chen HY, Huang BS, Lin YH, Su IH, Yang SH, Chen JL, et al. Identifying Chinese herbal medicine for premenstrual syndrome: implications from a nationwide database. BMC Complement Altern Med. 2014;14:206.View ArticlePubMedPubMed CentralGoogle Scholar
  31. Pan JC, Tsai YT, Lai JN, Fang RC, Yeh CH. The traditional Chinese medicine prescription pattern of patients with primary dysmenorrhea in Taiwan: a large-scale cross sectional survey. J Ethnopharmacol. 2014;152(2):314–9.View ArticlePubMedGoogle Scholar
  32. Yeh LL, Liu JY, Lin KS, Liu YS, Chiou JM, Liang KY, et al. A randomised placebo-controlled trial of a traditional Chinese herbal formula in the treatment of primary dysmenorrhoea. PLoS One. 2007;2(8):e719.View ArticlePubMedPubMed CentralGoogle Scholar
  33. Chen HY, Lin YH, Su IH, Chen YC, Yang SH, Chen JL. Investigation on Chinese herbal medicine for primary dysmenorrhea: implication from a nationwide prescription database in Taiwan. Complement Ther Med. 2014;22(1):116–25.View ArticlePubMedGoogle Scholar
  34. Lin YR, Wu MY, Chiang JH, Yen HR, Yang ST. The utilization of traditional Chinese medicine in patients with dysfunctional uterine bleeding in Taiwan: a nationwide population-based study. BMC Complement Altern Med. 2017;17(1):427.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Chen Z, Wu JB, Liao XJ, Yang W, Song K. Development and validation of an UPLC-DAD-MS method for the determination of leonurine in Chinese motherwort (Leonurus japonicus). J Chromatogr Sci. 2010;48(10):802–6.View ArticlePubMedGoogle Scholar
  36. Xiao Y, Liu YY, Yu KQ, Ouyang MZ, Luo R, Zhao XS. Chinese herbal medicine liu jun zi tang and xiang sha liu jun zi tang for functional dyspepsia: meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2012;2012:936459.PubMedPubMed CentralGoogle Scholar
  37. Chang CH, Cheng PY. Treatment of diarrhea-predominant IBS with Shenling Baizhu powder a case sduty. Taiwan J Clin Chin Med. 2009;15(2):118–21.Google Scholar
  38. Liu J. Shen Ling Bai Zhu San and its clinical application. Mintong Med J. 2014;452:14–6.Google Scholar
  39. Chen JK, Chen T. Chinese medical herbology and pharmacology. City of Industry: Art of Medicine Press; 2004.Google Scholar
  40. Chen HY, Lin YH, Huang JW, Chen YC. Chinese herbal medicine network and core treatments for allergic skin diseases: implications from a nationwide database. J Ethnopharmacol. 2015;168:260–7.View ArticlePubMedGoogle Scholar
  41. Chien PS, Tseng YF, Hsu YC, Lai YK, Weng SF. Frequency and pattern of Chinese herbal medicine prescriptions for urticaria in Taiwan during 2009: analysis of the national health insurance database. BMC Complement Altern Med. 2013;13:209.View ArticlePubMedPubMed CentralGoogle Scholar
  42. Cheng HM, Chiang LC, Jan YM, Chen GW, Li TC. The efficacy and safety of a Chinese herbal product (Xiao-Feng-San) for the treatment of refractory atopic dermatitis: a randomized, double-blind, placebo-controlled trial. Int Arch Allergy Immunol. 2011;155(2):141–8.View ArticlePubMedGoogle Scholar
  43. Chen HY, Lin YH, Chen YC. Identifying Chinese herbal medicine network for treating acne: implications from a nationwide database. J Ethnopharmacol. 2016;179:1–8.View ArticlePubMedGoogle Scholar
  44. Bing-sheng X. A botanical study of the Chinese drug Jin-yin-hua (author's transl). Yao Xue Xue Bao. 1979;14(1):23–34.Google Scholar
  45. Wong RW, Hagg U, Samaranayake L, Yuen MK, Seneviratne CJ, Kao R. Antimicrobial activity of Chinese medicine herbs against common bacteria in oral biofilm. A pilot study. Int J Oral Maxillofac Surg. 2010;39(6):599–605.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2018

Advertisement